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Page 1: Review Interventional Cardiology...Transradial peripheral vascular intervention 7 1 2015 Endovascular therapy for the interventional treatment of peripheral vascular disease is becoming

55Interv. Cardiol. (2015) 7(1), 55–76 ISSN 1755-5302

part of

InterventionalCardiology

Review

10.2217/ICA.14.67 © 2015 Future Medicine Ltd

Interv. Cardiol.

10.2217/ICA.14.67

Review

Truesdell, Delgado, Blakeley & BachinskyTransradial peripheral vascular intervention

7

1

2015

Endovascular therapy for the interventional treatment of peripheral vascular disease is becoming increasingly prevalent. Radial access is replacing femoral access for coronary intervention owing to its superior safety profile. These parallel advances forecast a future paradigm shift to routine transradial peripheral vascular intervention. This review highlights the technical challenges preventing immediate adoption of transradial peripheral vascular intervention, describes the technical aspects of the procedure in different anatomic beds utilizing currently available equipment, details the procedural, morbidity, and possible mortality benefits inherent to transradial access, reviews the available scientific evidence, and recommends a framework for successful transition to a radial strategy for peripheral vascular intervention.

Keywords:  angiography • endovascular intervention • peripheral vascular disease • transradial • vascular access • vascular complications

Peripheral vascular disease is a major source of morbidity and mortality worldwide [1,2]. It is present in up to 20% of persons over age 70, with symptomatic disease affecting nearly 6% of adults over age 60 [3,4]. Alongside efforts to increase public awareness and reduce modifi-able risk factors, there have been significant advances in the safety and efficacy of endovas-cular therapy for peripheral vascular disease. Endovascular intervention is increasingly becoming first-line therapy for the invasive management of vascular disease [4–10]. Due to parallel advances in transradial (TR) tech-niques for percutaneous coronary interven-tion (PCI), radial access is replacing femo-ral access as the dominant approach to PCI in many parts of the world [11,12]. Although high-quality evidence to support transradial peripheral vascular intervention (TRPVI) as a first-line strategy is currently lacking, two decades of TR coronary advances recom-mend a similar paradigm shift for peripheral vascular intervention (PVI).

The coronary experienceTR access began in earnest following initial reports of radial coronary angiography by

Campeau in 1989 and PCI by Kiemeneij in 1992 [13,14]. During the decades since, com-pared with femoral access, radial artery (RA) access has consistently demonstrated statisti-cally significant reductions in bleeding and access site complications regardless of the clinical condition, patient population or anti-coagulation status, despite significant paral-lel reductions in the incidence of transfemo-ral (TF) vascular complications [15–28]. These benefits directly translate into decreased morbidity and possibly mortality, particu-larly in high-risk patient subgroups such as the elderly, obese and those with severe peripheral arterial disease [15,19,20,23,28–42].

The RIVAL, RIFLE-STEACS and STEMI-RADIAL studies, an analysis of 2007–2011 US National Cardiovascular Data Registry data, and several recent meta-analyses all demonstrated both morbidity and mortality benefits to radial access in patients with ST-segment elevation acute coronary syndrome (ACS), most likely as a result of lower rates of bleeding and vas-cular complications with the TR approach [36,38,40,41,43–45]. A 2014 analysis by Iqbal et al. of 10,095 patients with non-ST-segment

Transradial peripheral vascular intervention: challenges and opportunities

Alexander G Truesdell*,1, Gabriel A Delgado2, Steven W Blakeley1 & William B Bachinsky1

1PinnacleHealth CardioVascular Institute, 

111 South Front Street, Harrisburg, PA, 

USA 2Novant Health Heart & Vascular 

Institute, 1401 Matthews Township 

Parkway, Matthews, NC, USA

*Author for correspondence: 

Tel.: +1 717 731 0101 

Fax: +1 717 731 8359 

[email protected]

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elevation myocardial infarction also demonstrated an association between TR access and reduced bleeding, access site complications and all-cause mortality in this population [42]. Most recently, an observational analy-sis of a nonselected cohort of nearly 350,000 patients between 2006 and 2011 from the British Cardiovas-cular Intervention Society database demonstrated TR access to be independently associated with reduced 30-day mortality for both ACS and non-ACS popula-tions [46]. Despite the absence of a definitive, adequately powered, multicenter, randomized control trial testing radial versus femoral access with contemporary medi-cations and techniques in ST-elevation ACS, non-ST-elevation ACS and non-ACS patients to directly assess mortality benefits based on access site alone, the weight of current evidence suggests a statistically significant mortality benefit to TR access for PCI.

Additional practical advantages repeatedly identi-fied in coronary studies are: earlier ambulation, short-ened length of stay, reduced resource and staff use, decreased hospital costs and increased patient comfort and satisfaction [19,20,28,30,35,36,38–40,47–49]. As a result, current transatlantic practice guidelines increasingly recommend the RA as the preferred access site for PCI [34,50].

Into the peripheryThe performance of peripheral interventions via the RA is designed to apply the numerous benefits of radial access strategies to noncoronary procedures. The proven reduction in bleeding and vascular com-plications with radial access is particularly pronounced in patients with significant peripheral arterial disease [12,15,17,19,21,51,52]. Absent femoral pulses, bilateral iliac artery disease, severe vessel calcification or tortuosity, coexistent aortic aneurysms or dissections or previous bilateral iliac stenting or aortobifemoral surgical recon-struction all complicate femoral access and interven-tion strategies, whether for coronary or vascular inter-vention [34,51,53]. Most of these technical difficulties are obviated by the radial approach.

Procedural advantagesFor subclavian, innominate, renal, mesenteric, celiac and some carotid interventions (such as a right internal carotid artery in the presence of a type III or severely diseased aortic arch or a left internal carotid artery aris-ing from the innominate artery), there are anatomic advantages to RA access due to more favorable angles of approach, better sheath and guide support and more coaxial vessel alignment [51,53,54].

Although brachial and axillary access strategies are feasible alternatives to femoral access, they are associ-ated with higher complication rates (as high as 36%

in some series) compared with radial access, especially among occasional operators [21,52,55].

Radial access additionally eliminates the need for postprocedure mechanical compression of the femoral arteriotomy, thereby reducing attendant risks of lower extremity ischemia and thrombosis [54]. From a techni-cal standpoint, there is no significant loss of catheter steerability or pushability from the RA compared with the femoral approach. Overall, TRPVI demonstrates at least similar efficacy with improved safety compared with the TF approach [39,56,57].

LimitationsWholesale adoption of radial access for peripheral intervention has been limited primarily by three major technical issues: the smaller diameter of the RA; radial, brachial, subclavian and aortic tortuosity; and most significantly, the extended distance to the target vessel. Ultrasound, radiographic and anatomic studies demonstrate a range of RA diameters, primarily from 2 to 4 mm, averaging approximately 2.4 mm in women and 2.6 mm in men [12,58–62]. Since the RA can typi-cally expand beyond its resting diameter, most patients can accommodate a 6 French (Fr) radial sheath (outer diameter 2.6–2.9 mm) [61]. Fewer patients’ vessels can routinely accept a 7 Fr sheath, often required for more advanced peripheral equipment, such as atherectomy or thrombectomy devices, cutting balloons and cov-ered stents [63,64]. In highly selected patients, up to 8 Fr sheaths can sometimes be utilized [61,65,66]. In addi-tion to these size constraints, current equipment length limitations also make it impossible to routinely perform comprehensive selective angiography and intervention below the inguinal ligament (Table 1 & Figure 1) [12].

ConcernsTR access has been associated with increased patient and operator radiation exposure, contrast use and procedural times compared with TF access in the coronary literature, particularly among less experi-enced operators [12,49,67]. When performing peripheral interventions, in addition to coronary radiation dose reduction strategies (such as positioning the radial access site close to the ipsilateral groin), lower frame rates and road map and mask functions may be used to reduce patient and operator radiation dose. Left radial access may also reduce radiation exposure compared with right radial access [68–70]. However, TR proce-dure time and radiation exposure is most influenced by operator experience, decreases with training and prac-tice and approximates TF exposure among practiced operators [37,71]. In the end, any differences must be balanced against the parallel reductions in access site complications and bleeding.

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Transradial peripheral vascular intervention Review

Table 1. Currently available equipment for transradial peripheral vascular intervention.

Company Product Guidewire (in) Sheath (Fr) Diameter (mm) Shaft length (cm)

PTA balloons

Abbott Armada 14 0.014 4 1.5–4 150

Viatrac 0.014 4–5 4–7 135

Armada 35 0.035 5–7 3–14 135

Bard Ultraverse 0.014–0.018 4–6 1.5–9 150–200

Vascutrak 0.018 5–7 4–7 140

Dorado 0.035 5–6 3–10 135

Boston Scientific Coyote 0.014 4 1.5–4 150

Sterling 0.018 4 2–4 150

Mustang 0.035 5–7 4–7 135

Cook Advance Micro 0.014 3 1.5–3 150

Advance 14 0.014 4 2–4 170

Advance 18–35 0.018–0.035 4–7 3–12 135

Cordis Sleek 0.014 4 1.25–5 150

Aviator 0.014 4–5 4–7 142

Savvy 0.018 4–5 2–6 150

Covidien NanoCross 0.014 4 1.5–4 150

PowerCross 0.018 4–6 2–6 150

EverCross 0.035 5–7 3–12 135

Medtronic Amphirion 0.014 4 1.5–4 150

Pacific 0.018 4–5 2–7 180

Admiral 0.035 5–7 3–12 130

Cutting, scoring or specialty balloons

Boston Scientific Flextome 0.014 137

Spectranetics AngioSculpt 0.014 –0.018 5–6 2–6 137

TriReme Chocolate 0.014–0.018 5–6 2.5–6 120–135

Self-expanding stents

Abbott AccuLink 0.014 6 5–10 135

Xact 0.014 6 5–10 135

Xpert 0.018 4–5 3–8 135

Supera 0.018 4.5–6.5 6–7 120

Absolute 0.035 6 6–10 135

Bard LifeStent 0.035 6 6–10 135

E-Luminex 0.035 6 4–14 135

Boston Scientific WallStent 0.014 6 6–10 135

Epic 0.035 6 6–12 120

Cook Zilver 0.018–0.035 6 6–10 125

Cordis Smart 0.035 6 6–10 120†Covered stent.‡Crown size.§Tip diameter.#Treatable vessel diameter.

CTO: Chronic total occlusion; Fr: French; N/A: Not applicable or not available; PTA: Percutaneous transluminal angioplasty.

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Company Product Guidewire (in) Sheath (Fr) Diameter (mm) Shaft length (cm)

Covidien Protege 0.014 6 6–10 135

EverFlex 0.035 6 6–8 120

Medtronic Complete 0.035 6 4–10 130

Gore Viabahn† 0.014–0.035 6–12 5–13 120

Balloon-expandable stents

Abbott Herculink 0.014 5 4–7 135

Omnilink 0.035 6–7 6–10 135

Atrium iCast† 0.035 6–7 5–12 120

Bard Valeo 0.035 6–7 6–10 120

Boston Scientific Express SD 0.018 5–6 4–7 150

Express LD 0.035 6–7 6–10 135

Cook Formula 0.014–0.018 5–6 4–6 135

Cordis Palmaz 0.018–0.035 4–7 3–10 135

Covidien VisiPro 0.018 6–7 5–10 135

Medtronic Racer 0.014–0.018 5–6 4–7 130

Assurant 0.035 6 6–10 130

Atherectomy devices

Bayer Medrad JetStream 0.014 7 1.6–3.4§ 120–145

Covidien TurboHawk 0.014 6–8 1.5–7# 104–145

CSI Stealth360 0.014 4–6 1.25–2‡ 145

Spectranetics Turbo Elite Laser 0.014–0.035 4–8 1.4–3.8# 112–150

CTO crossing and re-entry devices

Bard Crosser 0.014 5 N/A 146–154

Boston Scientific TruePath 0.018 4 N/A 165

OffRoad 0.035 6 N/A 100

Cordis FrontRunner N/A 5 N/A 140

Outback 0.014 6 N/A 140

Covidien Viance 0.014 5 N/A 150

Enteer 0.014–0.018 5 N/A 135–150

Medtronic Pioneer 0.014 6 N/A 120

Filters and embolic protection

Abbott Emboshield Nav6 0.014 5 N/A 135

AccuNet 0.014 6 N/A 145

Boston Scientific FilterWire 0.014 4 N/A 300

Cordis AngioGuard 0.014 4 N/A 135

Covidien SpiderFX 0.014 4 N/A 320

Medtronic FiberNet 0.014 6–7 N/A 150

MoMa 0.035 9 N/A 95†Covered stent.‡Crown size.§Tip diameter.#Treatable vessel diameter.

CTO: Chronic total occlusion; Fr: French; N/A: Not applicable or not available; PTA: Percutaneous transluminal angioplasty.

Table 1. Currently available equipment for transradial peripheral vascular intervention (cont.).

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Carotids:60–75 cm

Subclavian:50–70 cm

Renal:80–100 cm Common Illiac:

105–125 cmCommon femoral:

120–150 cm

Superficial femoral:130–170 cm

Foot: 200–250 cm

Popliteal:150–180 cm

Figure 1. Distance to vascular territories from left and right radial artery. Greater distances in listed ranges are from the right radial artery (vs the left). Values are derived from anatomic measurements of patients treated at the authors’ facilities as well as published literature. Reproduced with permission from [54] © Wiley Periodicals, Inc. (2012).

future science group

Transradial peripheral vascular intervention Review

Early transradial coronary trials demonstrated a consistently higher rate of access failure with radial versus femoral access (7.3 vs 2.0%) while later studies noted procedural failure and crossover rates of less than 5% [12,15,34,72]. More recent registries reveal crossover rates below 2% (and near 1% for dedicated radialists

utilizing modern techniques and equipment), consistent with historical data for femoral access [34,72–74].

Radial compared with femoral access also dem-onstrates very low and equivalent risks of neurologic complications and silent cerebral microembolization (0.11% for both radial and femoral access in a recent

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retrospective analysis of 370,328 coronary proce-dures) [75,76]. Event rates are also equivalent for left ver-sus right radial access (0.11 vs 0.08%) despite greater aortic arch traversal and sometimes increased catheter manipulation from the right radial artery [19,75,76].

DataOverall there are limited data and no large multicenter randomized studies evaluating TRPVI. Only one ran-domized trial for carotid intervention has been pub-lished to date [77]. Several observational studies, feasi-bility studies, technical reports, case reports, case series and single-center registries have demonstrated success-ful TR intervention for carotid, vertebral, subclavian, innominate, renal, iliac, celiac, mesenteric and superfi-cial femoral artery (SFA) disease (Table 2) [12,56–58,78–101]. The existing evidence base for TRPVI is further limited by the potential for literature bias, as very few studies have been published worldwide, most with very small numbers of patients, and all with positive outcomes.

Preprocedural evaluationPreprocedural patient evaluation is critical for success-ful TR intervention [12]. Ideal patients are less than 70 years of age and have an easily palpable radial pulse. The Allen’s, Barbeau (utilizing plethysmography) and ‘reverse’ Allen’s and Barbeau tests are sometimes performed to confirm dual circulation to the hand through the palmar arch [102–104]. These tests are less common outside of the USA and controversy exists regarding the clinical utility of routine testing prior to TR intervention [37,102–106]. Hand ischemia due to periprocedural radial artery occlusion (RAO) or RA harvesting for use as a bypass graft rarely occurs even with an abnormal Allen’s or Barbeau test owing to recruitment of interosseus collaterals [104–106]. Based on the weight of available evidence, the authors do not routinely perform Allen’s or Barbeau tests prior to TR angiography or intervention.

Vascular accessRadial access can be obtained either via a modified Seldinger anterior wall puncture or a standard Seld-inger posterior wall puncture. We routinely utilize the former approach in our laboratories, although some experts recommend the latter as a simpler, more reliable technique for less experienced radial opera-tors [107,108]. For poorly palpable radial pulses, a small volume of local anesthetic mixed with nitroglycerine may be injected subcutaneously at the arteriotomy site to promote arterial dilation and improve vessel palpa-tion and access success [12,109,110]. The authors presently use ≤1 ml of a solution of 1% Lidocaine (5–7 ml total volume) admixed with 200–500 μg of nitroglycerine

(100 μg/ml concentration). The RA may also be com-pressed distal to the site of arterial access to improve palpation [108]. Ultrasound-guided access has addi-tionally been shown to improve rates of first-attempt success, reduce arterial trauma and decrease vessel spasm, while also providing helpful real-time anatomic information regarding RA diameter [111].

The ideal arteriotomy site is located approximately 2–3 cm proximal to the radial styloid. More cranial access may be obtained when additional catheter length is required, albeit at the risk of complicating post-pro-cedure hemostasis. More distal, the RA is smaller in diameter, more tortuous and concealed beneath the flexor retinaculum, making access more challenging. Radial-specific sheaths are advised where available, as their progressive tapering and lubricated coating facili-tate insertion and reduce rates of spasm compared with standard femoral sheaths [34,112].

Tortuosity/variant anatomyVariant anatomy or tortuosity of the radiobrachial axis, axillary-subclavian axis or the aortic arch signifi-cantly impacts the likelihood of procedural success or failure [62,113–116]. Radial ‘loops,’ high-brachial or axil-lary origin of the RA, hypoplastic or accessory RA or combinations thereof occur in up to 10% of cases and are more common in older, hypertensive patients (Figure 2) [62,115,117]. While atherosclerosis of the radial artery occurs in up to 20% of subjects, multiple ultra-sound, angiographic, surgical and anatomic studies dem-onstrate clinically relevant stenosis that impacts radial artery blood flow or the success of transradial intervention to be rare [73,118–120]. In a recent review of 2211 consecu-tive radial interventions, a stenotic or hypoplastic radial artery was noted in 1.7 and 7.7% of subjects, respectively, with procedural success rates of 91.9 and 93.9% [120]. Overall, contemporary crossover rates for elective tran-sradial PCI range between 1 and 2%, are primarily due to radio-brachio-subclavian tortuosity or vasospasm, and have only rarely been attributed to atherosclerosis of the radial or brachial artery [34,73,118–120].

Radial artery spasmRA spasm is another common reason for TR proce-dural failure and occurs more commonly with bulkier and longer peripheral sheaths. Predictors of vasospasm are: older age, short stature, female sex, diabetes, low body mass index, small wrist circumference and radial sheath to RA ratio of < 1:1 [61,112,121,122]. The RA adven-titia is also widely invested with α-adrenoreceptors, making it particularly reactive to local trauma and circulating catecholamines [12,123,124]. So repeated arteriotomy attempts, fear, anxiety and pain routinely contribute to clinically relevant spasm [61,112,121,122].

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Transradial peripheral vascular intervention ReviewTa

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‡Radial spasm prevented sheath passage in one patient, carotid artery could not be cannulated in one patient.

§80 lesions in 74 patients.

#Two TR failures were successful via TF access.

¶One total occlusion could not be crossed by either the radial or femoral approach.

††32 lesions in 25 patients.

‡‡32 target lesions, 16 suprainguinal (6 common iliac, 10 external iliac), 16 infrainguinal (13 superficial femoral, 2 common femoral, 1 popliteal).

§§81% success for suprainguinal lesions, 81% success in infrainguinal lesions.

##93% success right carotid, 88% success bovine left carotid, 88% success standard left carotid.

¶¶38 target lesions, 16 suprainguinal (iliac), 22 infrainguinal (2 common femoral, 17 superficial femoral, 3 popliteal).

††† Radial artery rupture.

‡‡‡ TF to TR crossover rate 1.5% (2 iliac artery stenoses).

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##

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N/A: Not applicable or not available; SFA: Superficial femoral artery; TF: Transfemoral access; TR: Transradial access.

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aro

tid

130

(10

0)

TR

130

(10

0)

TF13

(10

)‡‡‡

Faile

d p

un

ctu

re

(2),

rad

ial

spas

m (

1); r

adia

l ar

tery

loo

p (

1);

sub

clav

ian

ste

no

sis

(1);

su

bcl

avia

n

tort

uo

sity

(1)

; ca

nn

ula

tio

n

dif

ficu

lty

(6)

1(1)

TR

§§

§ 1(

1) T

F[77]

† 27 lesions in 25 patients.

‡Radial spasm prevented sheath passage in one patient, carotid artery could not be cannulated in one patient.

§80 lesions in 74 patients.

#Two TR failures were successful via TF access.

¶One total occlusion could not be crossed by either the radial or femoral approach.

††32 lesions in 25 patients.

‡‡32 target lesions, 16 suprainguinal (6 common iliac, 10 external iliac), 16 infrainguinal (13 superficial femoral, 2 common femoral, 1 popliteal).

§§81% success for suprainguinal lesions, 81% success in infrainguinal lesions.

##93% success right carotid, 88% success bovine left carotid, 88% success standard left carotid.

¶¶38 target lesions, 16 suprainguinal (iliac), 22 infrainguinal (2 common femoral, 17 superficial femoral, 3 popliteal).

††† Radial artery rupture.

‡‡‡ TF to TR crossover rate 1.5% (2 iliac artery stenoses).

§§

§One symptomatic radial artery occlusion.

##

# 170 lesions in 110 patients.

N/A: Not applicable or not available; SFA: Superficial femoral artery; TF: Transfemoral access; TR: Transradial access.

Tab

le 2

. Maj

or

stu

die

s an

alyz

ing

th

e fe

asib

ility

, saf

ety

and

effi

cacy

of

tran

srad

ial p

erip

her

al v

ascu

lar

inte

rven

tio

n (

con

t.).

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Transradial peripheral vascular intervention Review

Stu

dy

Des

ign

Pop

ula

tio

n (

n)

Vas

cula

r te

rrit

ory

Pro

ced

ura

l su

cces

s (n

[%

])TR

to

TF

cro

sso

ver

(n [

%])

Rea

son

fo

r fa

ilure

o

r cr

oss

ove

r (n

)M

ajo

r ac

cess

sit

e co

mp

licat

ion

(n

[%

])R

ef.

Shin

oza

ki e

t al

. (20

14)

Ob

serv

atio

nal

, p

rosp

ecti

ve30

TR

Iliac

30(1

00

)0

N/A

0[93]

Lore

nzo

ni e

t al

. (20

14)

Ob

serv

atio

nal

, p

rosp

ecti

ve11

0 TR

##

#Su

pra

ing

uin

al

and

In

frai

ng

uin

al

154

(91)

N/A

N/A

0[58]

Ru

zsa

et a

l. (2

014

)O

bse

rvat

ion

al,

pro

spec

tive

27 T

RR

enal

27(1

00

)0

N/A

0[101]

† 27 lesions in 25 patients.

‡Radial spasm prevented sheath passage in one patient, carotid artery could not be cannulated in one patient.

§80 lesions in 74 patients.

#Two TR failures were successful via TF access.

¶One total occlusion could not be crossed by either the radial or femoral approach.

††32 lesions in 25 patients.

‡‡32 target lesions, 16 suprainguinal (6 common iliac, 10 external iliac), 16 infrainguinal (13 superficial femoral, 2 common femoral, 1 popliteal).

§§81% success for suprainguinal lesions, 81% success in infrainguinal lesions.

##93% success right carotid, 88% success bovine left carotid, 88% success standard left carotid.

¶¶38 target lesions, 16 suprainguinal (iliac), 22 infrainguinal (2 common femoral, 17 superficial femoral, 3 popliteal).

††† Radial artery rupture.

‡‡‡ TF to TR crossover rate 1.5% (2 iliac artery stenoses).

§§

§One symptomatic radial artery occlusion.

##

# 170 lesions in 110 patients.

N/A: Not applicable or not available; SFA: Superficial femoral artery; TF: Transfemoral access; TR: Transradial access.

Tab

le 2

. Maj

or

stu

die

s an

alyz

ing

th

e fe

asib

ility

, saf

ety

and

effi

cacy

of

tran

srad

ial p

erip

her

al v

ascu

lar

inte

rven

tio

n (

con

t.).

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64 Interv. Cardiol. (2015) 7(1)

A B

Figure 2. Radio-brachio-subclavian tortuosity. (A) Right radial artery ‘loop.’ (B) Right subclavian and innominate artery tortuosity.

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Successful antispasm strategies include generous patient sedation, small diameter hydrophilic sheaths and spasmolytic cocktails [34,112,125–128]. Prophylactic intra-arterial administration of agents known to reduce vascular tone, such as calcium channel blockers (most commonly 2–5 mg of verapamil or 200–500 mcg of nicardipine) and nitrates is critical to limit spasm, increase RA diameter, facilitate larger equipment insertion and improve procedural success [125,129,130]. When spasm does occur, further analgesia, sedation and spasmolytic therapy must be administered imme-diately. Untreated, severe spasm may prevent catheter advancement and manipulation or result in catheter entrapment (Figure 3) [34]. With contemporary equip-ment and spasm prevention strategies, the incidence of clinically relevant spasm has decreased to less than 1% [130].

Antithrombotic therapyAnticoagulation is required for TR angiography in order to reduce the risk of RAO [12,132]. Current expert consensus recommends administration of intra-arte-rial or intravenous unfractionated heparin at a dose of 50–70 μ/kg for diagnostic angiography [37]. Inter-ventional doses are similar to those recommended for femoral access [50].

Diagnostic angiographyFollowing successful RA access, a 4 or 5 Fr diagnos-tic catheter, typically the Judkins right (JR), multi-purpose (MP) or vertebral, is advanced over a 0.035 inch wire into the aortic arch. If any tactile resistance is encountered, angiography is performed to delineate the radio-brachio-subclavian anatomy. At the subcla-vian artery and beyond, fluoroscopy should always be employed to avoid injury to thoracic and abdominal branch vessels. Severe vessel tortuosity at any level between the entry site and the target vessel can usually be overcome using a hydrophilic steerable 0.035, 0.018 or 0.014 inch wire. If difficulty is encountered enter-ing the descending aorta, a JR catheter may be used in the left anterior oblique view to direct a 0.035 inch stiff-angled hydrophilic polymer-coated wire from the subclavian artery.

Aorto-iliac angiography is performed by power injection of the distal abdominal aorta through a straight 125 cm diagnostic pigtail catheter. Selective diagnostic angiography is then performed using a 125 cm JR, MP or vertebral diagnostic catheter or a 150 cm length 0.035 inch support catheter. Until longer length catheters enter production, infrailiac angiography may be more effectively performed from the left RA utiliz-ing a high radial puncture to provide up to 15–20 cm of additional length compared with distal right radial access [12].

Peripheral interventionRadial, and occasionally brachial, artery angiography should routinely be performed prior to consideration of TRPVI owing to the larger size of some peripheral interventional equipment. During diagnostic angi-ography, the distance from the RA access site to the iliac bifurcation or target vessel should also be mea-sured to further determine a patient’s eligibility for TR intervention.

Several expert operators advocate performing TRPVI via the left RA to avoid innominate artery tortuosity, catheter manipulation in the aortic arch and to provide additional length [54,108]. However, as with TR coronary procedures, the right-sided approach affords easier access, increased operator and patient comfort, is our preferred approach and in our Figure 3. Brachial artery spasm.

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opinion will likely become the community standard in the future [11,12].

After navigating upper extremity and thoracic tortu-osity, the initial hydrophilic wire should be exchanged for a stiff nonhydrophilic 0.035 inch wire for improved support for sheath advancement toward the target ves-sel. Afterward, the procedure progresses as from the femoral approach.

Adapting a technique utilized for endovascular aor-tic aneurysm repair, in the absence of radial-specific vascular sheaths for peripheral intervention, the authors apply sterile mineral oil to the external sheath surface as a lubricant to ease the passage of nonhydrophilic sheaths through the radial and brachial artery [133]. For some interventions, newly commercially available hydrophilic sheathless guide catheters with large inter-nal diameters may also be feasible.

In the event of vessel spasm limiting catheter or sheath advancement, liberal doses of intra-arterial vasodilators should be administered. The balloon-assisted tracking (BAT) technique, whereby a coronary balloon is partially protruded from the distal end of a guide catheter over a 0.014 inch angioplasty wire and inflated to low pressure, may also be used to facilitate atraumatic catheter passage through tortuous or spas-tic radial or brachial arteries (Figure 4) [116,117,131]. Until longer peripheral wires and more monorail equipment becomes available, when 300 cm length wires are inad-equate for crossing catheter and balloon exchanges in the periphery, the ‘jet exchange’ hydraulic extrac-tion technique is recommended, whereby continuous hydrostatic force is applied to the wire by injecting saline through the lumen of the catheter or balloon to maintain wire position as the catheter or balloon is withdrawn [134,135].

Subclavian & innominate interventionUpper extremity arterial disease is well suited to ipsilateral TR intervention. Success rates are high and complication rates low compared with the TF approach [82,91]. TR sheaths overall offer improved guide support for ostial lesions and chronic total occlusions (CTO) [54]. Other advantages are reduced guide manipulation in the aortic arch and reduced contrast use. Radial access may sometimes be more challenging due to a poorly palpable radial pulse with severe proximal subclavian stenosis and necessitate ultrasound guidance for successful first-attempt radial access.

A 2010 single-center retrospective review by Yu et al. described 14 cases of subclavian artery stent-ing using radial access, with procedural success in 13 cases (93%) and no neurologic or access site complica-tions [91]. The single failure in this small series was a CTO that could not be crossed from either the femo-ral or radial approach [91].

Figure 5 illustrates a case of successful transradial left subclavian artery stenting in a 68-year-old woman with high-grade left subclavian artery stenosis and subclavian steal syndrome scheduled to undergo left internal mammary artery (LIMA) to left anterior descending coronary artery bypass surgery.

Carotid artery interventionCarotid artery stenting (CAS) via the radial approach has been demonstrated to be safe and effective in several small feasibility studies and one multicenter prospective randomized study [77,78,80,136]. The TR approach is most useful in patients with right internal carotid artery lesions, complex arch anatomy or severe aorto-iliac tortuosity or disease [54,78,137].

A B C

Figure 4. Balloon-assisted tracking. (A) Angiogram of successful balloon-assisted tracking (BAT) of guide through tortuous, stenosed and spasmodic right radial artery. (B &C) Illustration of BAT technique. (B & C) Adapted with permision from [131] © Wiley Periodicals, Inc. (2013).

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Etxegoien et al. published the largest series of CAS via RA access in 2012, a retrospective analysis of 382 patients, demonstrating a 91% success rate (93% for right carotid lesions and 88% for both standard and ‘bovine’ left carotid lesions) [96]. Inadequate sheath support was the cause of failure in the unsuccessful cases [96]. There were no bleeding complications [96]. Major and minor strokes occurred in 0.6 and 1.0% of patients, respectively [96]. More recently, in 2014, Ruzsa et al. published the only multicenter prospec-tive randomized study of TRPVI, comparing TR and TF access in 260 consecutive patients undergo-ing CAS [77]. Procedural success was 100%, with a crossover rate of 10% in the TR group (due to failed puncture, RA spasm, RA and subclavian tortuosity,

subclavian stenosis or severe carotid angulation) and 1.5% in the TF group (due to iliac artery stenosis) [77]. Major access site complications occurred in one patient (0.9%) in both the TR and TF arms [77]. Procedure and fluoroscopy times were comparable, but radiation dose was significantly higher in the TR group [77].

Figure 6 demonstrates a successful case of right internal CAS via the right radial artery in a 64-year-old man with symptomatic high-grade right internal carotid artery stenosis.

Vertebrobasilar interventionIpsilateral TR access for vertebral artery intervention is technically easier than the femoral approach and thus preferable to TF intervention [79]. As with sub-clavian and carotid intervention via the RA, access site complications are also nearly absent.

A feasibility study by Patel et al. in 2009 demon-strated a 100% success rate in 42 vertebral artery and 5 basilar artery interventions [79]. There were no bleed-ing complications [79]. Transient periprocedural stroke occurred in three patients (6%) and fatal intracranial hemorrhage occurred in one patient (2%), comparable to rates from TF access in historical studies [138].

Renal, celiac & mesenteric interventionRenal, celiac and mesenteric arteries are ideal for TR intervention due to their downward oriented take-off from the abdominal aorta and typically aorto-ostial disease, maximizing coaxial cannulation and improv-ing guide support from above [56,85,101,139–141]. In con-cert with the ‘no-touch’ technique (whereby a 0.035 inch J wire is directed caudally from the tip of the guide catheter to prevent contact with the aortic wall, while a 0.014 inch wire inserted through the same guide is used to cannulate the renal artery), TR renal artery intervention also significantly reduces traumatic vessel intubation [142].

Recently, clinical indications for renal artery stent-ing have become more controversial [142–144]. Although several randomized controlled trials failed to dem-onstrate significant advantages to renal artery stent-ing over medical therapy alone, these studies likely excluded groups of patients who may have benefited from intervention [143]. Current expert consensus still recommends consideration of renal artery stenting for severe hypertension with flash pulmonary edema or acute coronary syndrome, resistant hypertension and unexplained ischemic nephropathy with chronic kidney disease, among other indications [144].

Trani et al., in 2009, reported 100% procedural suc-cess in 62 consecutive patients undergoing renal artery stenting [85]. A 2011 study by Alli et al. evaluated the feasibility of TR renal intervention in 11 patients and

A

B C

Figure 5. Transradial subclavian artery stenting. (A) Left subclavian artery stenosis visualized via left radial angiography. (B) Subclavian stent deployment. (C) Final angiography demonstrating resolution of the stenosis and preserved left internal mammary artery flow.

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compared safety parameters to a matched group of 44 TF controls [98]. All TR interventions were successful with no complications [98]. There was one access cross-over due to insufficient guide length from the right RA [98]. There were no access site complications in the TR group and 3 (7%) in the TF group [98].

Figure 7 depicts successful left renal artery stenting in a 60-year-old man with severe systemic hyperten-sion refractory to maximal doses of five antihyperten-sive agents and Duplex arterial ultrasound evidence of bilateral renal artery stenosis. Bilateral stenting was per-formed and the patient’s hypertension was ultimately managed with lower doses of three antihypertensive agents.

Aorto-iliac interventionTR aorto-iliac angioplasty and stenting is feasible and safe [57,58,83,87,93]. Intervention can typically be per-formed through a 110 cm 6 Fr introducer sheath posi-tioned in the distal aorta or ostial common iliac artery. For ease of equipment exchange, the authors sometime remove the tuohy-borst valve and replace it with a compatible hemostatic valve. The long straight seg-ment of sheath in the descending aorta provides a high degree of support to iliac intervention from the RA. Antegrade angiography from above facilitates precise stent positioning for ostial common iliac lesions com-pared with the crossover technique and allows access to the entire length of the external iliac artery compared with the retrograde femoral approach. In addition, bilateral iliac disease can be treated in the same pro-cedure from a single access site [100]. When the distal aorta is involved or kissing balloon or stent technique is required bilateral radial access may be obtained.

Cortese et al. in 2014, published the largest series of TR iliac interventions (149 patients) [97]. Procedural success was achieved in 98.7% of patients [97]. Cross-over rates were 12.7% (the TF approach was used in 19 patients after unsuccessful attempts to cross the lesion from above) [97]. There were no reported vascu-lar access or procedure-related complications [97]. Pro-cedure length, fluoroscopy time and contrast volume were comparable to historical TF controls [97].

Infrainguinal interventionRoutine TR femoropopliteal intervention is cur-rently prevented by a lack of sheaths, balloons, stents and atherectomy devices of appropriate length and diameter. Ideally, the common iliac, external iliac or common femoral artery (CFA) should be selectively engaged with a long introducer sheath for sufficient support of infrainguinal intervention. At present, TR femoropopliteal intervention is primarily limited to focal lesions or in-stent restenosis [84]. Made-to-order

low-profile long-shaft balloons and self-expanding stents and 400 cm length wires have been used suc-cessfully outside of the USA for infrainguinal inter-vention [92]. Most atherectomy devices are limited by short shaft lengths and larger diameters and at present orbital and laser atherectomy are the only 6 Fr compat-ible devices [81].

For infrainguinal intervention, radial access may also be expected to reduce the incidence of access site complications compared with the crossover technique or antegrade femoral puncture. Where technically feasible, TR infrainguinal intervention additionally offers the potential benefit of treating bilateral disease during a single procedure.

In 2014, Lorenzoni et al. reported their experience treating 93 infrainguinal lesions in 110 consecutive patients undergoing lower extremity intervention via the TR approach [58]. Success rate was 90% (99% for 74 stenoses and 56% for 19 occlusions) with no bleeding or access site complications [58].

Figure 8 exhibits successful transradial left iliac stenting and left SFA PTA in a 96-year-old woman with chronic kidney disease and limb-threatening left lower extremity critical limb ischemia and nonhealing

A B C

Figure 6. Transradial carotid artery stenting. (A) Right internal carotid artery stenosis visualized via right RA angiography. (B) Carotid stent deployment. (C) Final angiography after successful intervention.

A B

Figure 7. Transradial renal artery stenting. (A) Left renal artery stenosis visualized via right RA access. (B) Final angiography after successful stenting.

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ulcers. Final angiography demonstrated restoration of inline flow to the left foot. The patient ultimately healed her left lower extremity ulcer.

Patent hemostasisAt the conclusion of TR angiography or intervention, the RA sheath is immediately removed and hemostasis achieved with external vessel compression. Utilizing any number of commercially available radial compres-sion bands, compression pressure should be titrated to establish nonocclusive hemostasis (using confirma-tory plethysmography) and progressively adjusted over 1–2 h to maintain adequate antegrade arterial flow throughout the hemostasis process [12,27,145]. Atten-tion to patent hemostasis reduces the risk of RAO and increases the likelihood of successful repeat radial access in the future [145–147].

Radial-specific complicationsVascular complications are trivial in number and sever-ity with TR intervention compared with TF interven-tion owing primarily to the RA’s superficial course, isolation from other vascular structures, and easy compressibility. Radial-specific complications include RA spasm, vessel perforation, bleeding, pseudoaneu-rysm formation and RAO [124]. Although uncommon compared with femoral access, these complications are more frequently observed in the presence of variant anatomy and vessel tortuosity [62,115,148].

Catheter entrapmentProlonged RA exposure to large, long peripheral sheaths increases the likelihood of clinically signifi-cant RA spasm. It is best prevented with liberal intra-arterial vasodilator administration, pain control, seda-tion and patience [125,129,130]. Severe spasm preventing catheter removal post-procedure may warrant axillary nerve block, deeper conscious sedation with propofol or general anesthesia [130,149]. Forceful removal of an entrapped catheter may cause partial or complete RA transection or eversion endarterectomy [25,149].

Vascular injuryRadial or brachial artery dissections are retrograde events and often seal spontaneously. Perforations are rare, occur in 0.1% of cases, and are easily managed compared with similar vascular injuries in the femo-ral and iliac region [150,151]. The preferred course of action is to obtain or maintain access across the site of injury and internally tamponade the site with the cath-eter, permitting the procedure to continue [106,150,151]. A recent small case series demonstrated 100% success with this technique [151]. Removing the catheter will leave an unsealed dissection or perforation that may require external control with brachial sphygmoma-nometer cuff inflation and placement of a loose elastic bandage around the forearm (Figure 9) [34,53]. Associ-ated hematomas are often easily controlled with manual pressure and rarely (0.004% in a recent large case series) progress to limb-threatening forearm compartment syndrome [49]. Immediate therapy includes cessation of anticoagulation, blood pressure control and external compression [12,34,152,153]. Vascular surgery consultation is recommended in the rare case of threatened limb ischemia.

Radial artery occlusionNonocclusive RA injury and asymptomatic RAO occur in up to 10% of patients after transradial catheterization, most commonly with large artery-catheter mismatch, female sex, diabetes, occlusive hemostasis and lack of heparin and antiplatelet pretreatment [12,61,132,145,154].

A B

C D

Figure 8. Transradial suprainguinal and infrainguinal intervention. (A) Initial diagnostic angiography performed via the right RA demonstrating occlusion of the left common iliac artery. (B) Serial occlusions of the left superficial femoral artery after successful wire traversal. (C) Final angiography following successful left iliac artery stenting. (D) Final angiography after successful left superficial femoral artery percutaneous transluminal angioplasty..

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Figure 9. Radial artery perforation secondary to forceful guide advancement.

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Transradial peripheral vascular intervention Review

RAO may prevent the use of the RA for future catheter-ization or for use as a bypass conduit or hemodialysis fistula. It is best prevented by immediate sheath removal and patent hemostasis. With proper procedural heparin dosing and patent hemostasis strategies, RAO rates have dropped to 2–5% at 24 h post-procedure in recent stud-ies [145]. Spontaneous recanalization also occurs com-monly, and rates of RAO are now less than 1–2% at 30 days [133,154,155]. With proper procedural technique, repeated TR arterial access has been performed for up to ten procedures at some centers [146,147].

TrainingExisting North American and European guidelines for recommended learning steps and competency rec-ommendations for TR coronary interventional train-ing should be used as a model for any operator aim-ing to explore TRPVI [12,34,37]. Similarly established TR coronary best practices should be translated to TRPVI [37].

The novice TRPVI operator should already have demonstrated competency in both TR coronary intervention and peripheral endovascular interven-tion [37,156]. While the learning curve has been sug-gested to be at least 50 cases for coronary TR com-petence among experienced operators, it is unknown for TRPVI, but may be similar for physicians already skilled in both peripheral vascular and TR interven-tion [157]. Building on the successful coronary model, there is also a need for structured TR peripheral vascu-lar training in fellowship programs as well as organized professional courses, simulators and mentorships [37].

Future perspectiveThe movement toward increased performance of TR coronary procedures should ultimately translate into greater adoption of the TR approach for peripheral vas-cular angiography and intervention. As technological advances in sheath and catheter design and miniatur-ization of interventional equipment proceeds, routine TRPVI may be expected to become more feasible and popular.

At present, there are little clinical data comparing the TR and TF approaches for PVI. Future random-ized controlled trials are needed for head-to-head comparison of TR and TF access.

In the near-term, there is also a need for a larger variety and longer length of radial-specific hydrophilic introducer sheaths in 125 and 150 cm lengths. Thin-ner wall peripheral sheaths with smaller outer diam-eters and larger inner diameters should be developed to permit interventions via 5 or 6 Fr sheaths. At the same time, future self-expanding stents need to be downsized without loss of radial force [158].

The 0.014 inch, 0.018 inch and 0.035 inch guide-wires should extend to 400 cm without sacrificing torque control and crossing capability [63]. Continued development of longer length support catheters for over-the-wire exchanges and new rapid exchange sys-tems is advised. Balloons should be produced in shaft lengths up to 200 cm. Finally, CTO devices, re-entry devices, atherectomy tools and intravascular ultra-sound catheters should be developed in longer lengths and smaller diameters. The numerous potential ben-efits of TRPVI clearly justify continued development of such radial-specific devices and equipment.

Drug-coated balloon (DCB) technology may be the best immediate answer to TR femoropopliteal interven-tions, and ultimately below the knee (BTK) interven-tions. DCBs mechanically disrupt plaque and infuse an antiproliferative agent throughout the treated lesion, and may be particularly useful in anatomic situations where stents perform poorly such as bifurcations, dis-tal pedal arteries, complex lesions, long segments and common femoral and popliteal artery lesions [159,160]. This may also increase use of atheroablative devices for improved vessel preparation once longer shaft length and smaller diameter equipment comes to market.

Beyond DCBs, bioresorbable vascular scaffolds may soon provide optimal transient scaffolding of the heal-ing vessel and continued antiproliferative drug elution to counteract excessive neointimal hyperplasia and then be reabsorbed, with restoration of normal vessel endo-thelial structure and function [161,162]. These and other technical advances should increase the type and severity of lesions amenable to TR endovascular intervention.

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BTK interventions may also someday benefit from dual radial and pedal access techniques to improve success rates [163–166]. Many of the procedural skills learned perfecting TR intervention translate well into pedal access for BTK intervention [167,168]. This addi-tional expertise will provide the endovascular interven-tionalist with a wider spectrum of therapeutic options. The day is not far off when ‘radial first’ may apply to interventions throughout the vascular tree.

ConclusionThe benefits of TR compared with TF access are by now well established. Peripheral vascular interven-tion continues to transition to an endovascular first approach. Building upon these advances, TRPVI holds the promise of superior safety and superior effi-cacy for the treatment of peripheral vascular disease.

A radial-first strategy is currently hampered by the absence of: randomized clinical trials and expert con-sensus, full-spectrum radial-specific equipment and a critical mass of suitably trained operators. The immense potential benefits of TRPVI justify the development of validated training pathways and competency standards and the manufacture and marketing of smaller, lon-ger and radial-specific peripheral vascular equipment. Combined with parallel ongoing advances in DCB and BVS technology as well as increased adoption of pedal access strategies, another major revolution in the interventional treatment of peripheral vascular disease is on the horizon.

AcknowledgementThe authors would like to thank EA Morgan, MLS for library 

services support.

Executive summary

Advantages of radial access• Compared to femoral access, the radial approach for coronary angiography and intervention has

demonstrated consistent reductions in bleeding, access site complications, morbidity, and possibly mortality across most patient populations studied.

• The clinical benefits of radial access are even more pronounced in patients with significant peripheral vascular disease.

• Clear anatomic advantages to radial access exist for peripheral intervention in innominate, subclavian, renal, mesenteric and celiac arteries, as well as carotid arteries in the presence of complex arch anatomy or severe aorto-iliac tortuosity or disease.

Current limitations of transradial peripheral vascular intervention• Wholesale immediate adoption of transradial peripheral vascular intervention (TRPVI) is limited in part by the

smaller diameter of the RA and the larger Fr size of many peripheral vascular devices.• Existing equipment length limitations constrain default infrainguinal angiography and intervention.• The coronary literature evidences increased contrast use, radiation exposure and procedure times for

transradial (TR) versus transfemoral intervention during the learning period.Lack of prospective data, randomized clinical trials, expert consensus & clinical guidelines• There is limited high-quality scientific data and no large multicenter randomized controlled trials to support

TRPVI.• Only one randomized trial for TRPVI (for TR carotid intervention) has been published to date.• Several observational studies, feasibility studies, technical reports, case reports, case series and single-center

registries have demonstrated successful TR intervention throughout the vascular tree.Technical aspects of TR angiography & intervention• Detailed preprocedural evaluation is critical to identify suitable candidates for TRPVI.• Comprehensive spasm prevention strategies are key to successful TR intervention.• Validated TR coronary procedural techniques may be utilized to successfully negotiate tortuosity and variant

anatomy of the radio-brachial and aorto-subclavian axes during TRPVI.• During diagnostic angiography, measuring the distance from the RA access site to the target vessel is

mandatory to determine a patient’s eligibility for TR intervention.• Proven guideline-supported femoral endovascular and coronary TR techniques can be combined for the

effective performance of TRPVI by experienced operators.Training & competency• Existing TR coronary guidelines and best practices should be used as a model for physicians expanding to

TRPVI.• Operators should demonstrate TR coronary and peripheral vascular interventional proficiency as prerequisites

to the performance of TRPVI.• Structured training programs are needed to develop more widespread TRPVI expertise among endovascular

interventionalists.

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Financial & competing interests disclosureWB Bachinsky has received honoraria and research grants from 

Abbott Vascular and Cordis. The authors have no other rele-

vant affiliations or financial involvement with any organization 

or entity with a financial  interest  in or financial conflict with 

the  subject matter  or materials  discussed  in  the manuscript 

apart from those disclosed. No writing assistance was utilized 

in the production of this manuscript.

ReferencesPapers of special note have been highlighted as:• of interest; •• of considerable interest

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Review Truesdell, Delgado, Blakeley & Bachinsky


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